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INSTRUCTIONS
1. All sections of
this form must be
completed in order
to comply with
DEP notification
requirements of
310 CMR 7.15
and the Division
of Occupational
Safety (DOS)
notification
requirements of
453 CMR 6.12
Commonwealth of Massachusetts 302035
Please Enter Decal #
Asbestos Notification Form ANF-001
A. Asbestos
1. Facility Location: 2 ��
Auto Repair Shop 631 East Street u' -'
Name of Facility Street Address i
Mansfield MA 02048 J`tii APR 04
City/Town State Zip Code Telephone
Worksite Location: E y
2nd Floor Office, Hall
Building name, #, wing, floor, room.
2. Is the facility occupied? ❑ Yes ® No
3. Asbestos Contractor
Dec -Tam Corporation
50 Concord St
Name
Address
N. Reading. MA 01864
978-470-2860
City/rown Zip Code
Telephone
AC000035
Contract Type: ® Written ❑ Verbal
DOS License #
Craig Starkman
Salesman/Estimator
Facility Contact Person
Contact person's title
Charles Brewer
ASB30534
4. Name of On -Site Supervisor/Foreman
DOS Certification #
Axiom Partners
AA000179
5' Name of Project Monitor
DOS Certification #
Axiom Partners
AA000179
6. Name of Asbestos Analytical Lab
DOS Certification #
2. Submit Original
Form to:
Commonwealth of
Massachusetts 7
Asbestos Program
PO Box 120087
Boston MA
02112-0087
04/11/05
Project Sta
7:00 am - 4:00
Work hours Mon-F
B. What type of project is this?
® Demolition ❑ Renovation
❑ Repair ❑ Other, please specify:
9. Check abatement procedures:
❑ Glove bag
❑ Enclosure
❑ Cleanup
® Full containment
❑ Encapsulation
❑ Disposal only
❑ Other, specify:
04/11 /05
End Date
Work hours Sat -Sun.
10. Is the job being conducted: ® Indoors? ❑ Outdoors?
05010126 Callahan Mansfield • 9/02 Asbestos Notification Forth - Page 1 of 4
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
302035
Please Enter Decal #
A. Asbestos Abatement Description (cont.)
11. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
encapsulated:
400
pipes or duwts (linear ft)
other surfaces (square ft)
Boiler, breaching, duct, tank surface
/
Insulating cement
lin. ft
/
sq. ft
coatings
lin. ft
sq. It
Corrugated or layered paper pipe
lin. ft
/
ft
Trowel/Sprayer coatings
lin. ft
/
sq. ft
insulation
sq.
Spray -on fireproofing
lin. ft
sq. ft
Transite board, wall board
lin. ft
sq. ft
Cloths, woven fabrics
lin. ft
/
sq. ft
Other,leaseseci
p specify:
/
/400
Thermal, solid core pipe insulation
lin. ft
sq. ft
Vinyl Floor Tile
lin. It
sq. It
12. Describe the decontamination system(s) to be used:
Three Chamber
13. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (g):
Material will be wetted and placed in double baps and labeled for transporatation
14. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
NameofDEP
Date of Authorization
DOS official
Date of Authorization
Waiver #
15. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? ❑ Yes ® No
B. Facility Description
1. Current or prior use of facility: Auto Repair Shop
2. Is the facility owner -occupied residential with 4 units or less? ❑ Yes ® No
Callahan, Inc.
631 East Street
3' Facility Owner Name
Address
Mansfield
02048
508-279-0012
CityfTown
Zip Code
Telephone
Robert Leland
631 East Street
4' Name of Facility Owner's On -Site Manager
Address
Mansfield
02048
508-279-0012
City/rown
Zip Code
Telephone
05010126 Callahan Mansfield • 9/02 Asbestos Notification Form • Page 2 of 4
Commonwealth of Massachusetts 302035
Please Enter Decal #
Asbestos Notification Fora' ANF-001
B. Facility Description (cont.)
n/a
5. Name of General Contractor
Address
Cityrrown Zip Code
Telephone
AIG
WC9694329 12/31/05
Contractor's Worker's Comp. Insurer
Policy # Exp. Date
2
6. What is the size of this facility?
tY
Sguar Square Feet # of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos -containing material from site to temporary storage site (if necessary) to final
disposal site:
Service Transport
58 Pyles Lane
Note: Transfer
Name of transporter
Address
Stations must
New Castle 19720
877-999-9659
comply with the
Cityrrown Zip Code
Telephone
Solid Waste
Division
2, Transporter of asbestos -containing waste material from removal/temporary site to final disposal site:
Regulations 310
CMR 19.000
n/a
Name of transporter
Address
Cityrrown Zip Code
Telephone
3.
Refuse transfer station and owner
Address
Cityrrown zip Code
Telephone
4. Minerva Landfill
n/a
Final Disposal Site location name
Owners Name
9000 Minerva Road
Waynesburg
Address
Cityrrown
OH 44688
330-866-3435
State Zip Code
Telephone
D. Certification r
The undersigned hereby states, under the
penalties of perjury, that he/she has read
the Commonwealth of Massachusetts
Note: Contractor regulations for the Removal, Containment
must sign this form or Encapsulation of Asbestos, 453 CMR
for DOS notification 6.09,and 310 CMR 7.15, and that the
purposes information contained in this notification is
true and correct to the best of his/her
knowledge and belief.
Craig Starkman
Name
Sales Estimator
Positionrritle
ut ize. Signature and Date
Dec -Tam
Representing
978-470-2860 50 Concord St
Telephone Address
N. Reading,MA 01864
Cityrrown Zip Code
Fee exempt (city, Town, district, municipal housing authority, owner -occupied residential of four units or less?) ❑ Yes ® No
05010126 Callahan Mansfield - 9/02 Asbestos Notification Form - Page 3 of 4